Breaking Bad News: A Side of Medicine That Is Not Easy, by Sahil Munjal, MD

Have you ever had a sinking feeling in your stomach when you are about to tell something to a patient or family member that might change their life forever? I had that feeling before speaking to the wife of my patient, Mr. Smith. It had only been one day since Mr. Smith was first admitted to the inpatient unit but regardless of how long the interaction is with a patient and their loved ones, some news is always difficult to deliver.

Mr. Smith was a 59-year-old artist who was admitted to the inpatient psychiatric unit for complaints of acutely worsening depression and disorganization. As I interacted with him and looked deeper into his history, something didn’t make sense. He kept arranging his feet symmetrically on the floor and analyzed patterns around the room. He would either stare into space when he was asked questions or he would respond by saying, “I can understand what you are asking but I don’t know what happens next and I cannot answer.” Looking at Mr. Smith’s age and symptoms, we considered a neurological cause.

The next morning, Mr. Smith underwent a CT scan and in the afternoon I got a call from the radiologist to discuss the results. The CT scan showed a large frontal lobe mass which in turn was pressing on the adjacent structures. In most cases finding the cause of a patient’s illness feels good, usually it means moving one step closer to diagnosing and curing a disease along with validating our rigorous medical training. However, this situation was different. After hearing the results, all I could think about was the catastrophic implications on the patient and his family from having a tumor this large. I was frantically making phone calls to neurology and neurosurgery to figure out the next steps when I realized I would have to break the news to Mr. Smith’s wife of 29 years. I felt a chill go up my spine at the thought of that. I had spoken to her the day before when she brought her husband into the hospital. I remembered the concern in her eyes as she discussed the escalation of his bizarre and disorganized behavior and I could sense the deep emotional bond between them. I kept wondering how I would break the news to her about the tumor and how she would react as she realized the implications. I couldn’t begin to understand how she would feel after hearing the news. I didn’t know what the best way was to tell someone this. To figure how to break the news to Mrs. Smith, I started asking myself questions like, “What if this was my relative or loved one? How would I take this information? In what way would I want to be told news like this if I was in her place?” Though I had told Mr. Smith the results of the CT scan, he could not understand the implications due to his state of disorganization. I knew his wife’s reaction would be very different.

The end of the day approached and I decided to stay longer that night. This was not the type of news anyone wanted to hear over the phone on their drive home from work, so I had decided I would talk to Mrs. Smith in person during visiting hours. As I waited for her, I thought about how much the topic of breaking bad news to patients or family members had been overlooked in medical school. I never realized how difficult it was to give someone bad news of this proportion and no matter how I did it, it wouldn’t be easy for me to say or for the patient and their loved ones to hear. I sat across from Mrs. Smith and told her the results of the CT scan, her face filled with fear and tears rolled down her cheeks. It was heart wrenching to see her breakdown like that. I can’t begin to imagine how it would feel to listen to such news about a loved one. Even though I was able to diagnose Mr. Smith, in the moment of giving the news to his wife, I was not a ‘super doctor’ who knew it all. In that moment I became as fallible as anyone else. I don’t remember my exact words to Mrs. Smith, but I do remember the fear that I felt while wondering, “What if I was in her place listening to this news about the one I love.” After answering all her questions to the best of my knowledge, I gave her some time and space to gather her thoughts and recover from the shock. She eventually held my hand and said, “I am glad that you were able to find it as quickly as possible.” Even though this didn’t change the patient’s eventual situation, I felt relieved seeing the strength his wife had.

Mr. Smith was transferred to neurosurgery, the brain biopsy demonstrated high-grade glioblastoma multiforme requiring surgical intervention. I visited him a few times after his surgery and he did have some improvement in his presenting symptoms. A few months later when I called Mr. Smith to follow-up on his wellbeing, Mrs. Smith mentioned he wasn’t doing well physically and still had persistent episodes of impulsivity, but I could hear her smile as she said, “He still maintains his sense of humor.” Even though they were going through difficult times, she was grateful for the positive things they still had.

A year later I saw Mr. Smith’s obituary in the newspaper. Having spent time with him and his wife during his diagnosis and treatment, I had formed a bond with them. I couldn’t help but feel sad and wonder how his family was doing. To my surprise, a few months later, I received a call from Mrs. Smith inviting me to her late husband’s posthumous art function. She also said that she and Mr. Smith’s parents wanted to thank me for what I did to help prolong his life. She said, “We will remember you for our entire lives.” This was one of the most memorable moments of my professional career. This case wasn’t ideal. I couldn’t cure the patient, but knowing that I made a difference even in such circumstances felt rewarding. It validated the reason I came into this profession, to make a difference in the lives of people.

After this experience, I appreciate how we as doctors make a difference not just in the life of a patient but also their family. I now realize how even in the toughest of situations, breaking bad news in an empathetic way along with being involved in the struggle of loved ones can make a difference in their suffering. I have learnt that the discussion should be in a place with some privacy, away from distractions, using simple language to discuss all the facts that are known or unknown and giving the caregiver space to understand the information. As we can never fully understand what the caregiver is going through, the best approach is to validate and support their emotions. In these situations, I also believe moving closer to the caregiver or even maintaining a physical contact like putting a hand on their shoulder is appropriate as it facilitates a sense of comfort for the caregiver. Being there for the patient and their family, understanding what they are going through, and making us available for questions to mitigate their uncertainty helps them in their ability to process the situation. I know the sinking feeling in my stomach will be there every time I have to disclose bad news to a patient and their family, but I also know that doing so in the right way as in this case can make a difference in the overall struggle they face.

Dr. Sahil Munjal, MD is the chief resident in psychiatry at New York Medical College.

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